DISCUSSION Study on Under 5 Deaths in Malaysia in the Year 2006
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per 1000 life births was added to the rate in our study, we had an under 5 mortality rate of 7.2 per thousand life births.
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Data from the National Registration Department showed that in 2003 there were 2421 deaths and 56.2 were hospital and 43.8 were non hospital deaths whereas in our
2006 study there were 1699 deaths and 76.7 were hospital and 23.3 were non hospital deaths. In 2003 the five most common causes of death were infectious and
parasitic diseases 17.4, congenital malformations, deformations and chromosomal abnormalities 15.2, injuries poisoning and external causes 13.5, diseases of the
respiratory system 13.5 and signs and symptoms and abnormal findings NEC 11.5 whereas in 2006 the five most common causes were congenital malformations,
deformations and chromosomal abnormalities 25.1, certain infectious and parasitic disease 18.8, diseases of respiratory system 13.0, diseases of nervous system
8.2 and injuries, poisoning and external causes 7.5. In the year 2003, injuries poisoning and external causes were the third commonest cause of death 13.5 as
compared to the year 2006, where injuries poisoning and external causes were the fifth commonest cause of death 7.5. From these comparisons, it could be concluded that
there was very likely under reporting of non hospital deaths especially in the classification injuries, poisoning and external cause; hence a lower percentage of non
hospital deaths in our study. Risk Factors
This study identified children in this country who were at higher risk of dying before the fifth birthday. These were children who lived in the states of Sabah, Pahang, Kelantan,
WPKL and Sarawak, who were less than 1 year old, of male gender, of ethnicity ‘other Malaysian’ ie Orang Asli, Bumiputera Sabah and Bumiputera Sarawak and with one or
more of the co-morbid conditions congenital anomalies, congenital heart disease, malnutrition and conditions from the perinatal period. Overall they were more likely to die
from congenital malformations, deformations and chromosomal abnormalities but children in the ethnic groups Orang Asli, Bumiputera Sabah and Bumiputera Sarawak
and non citizen were more likely to die from infections like acute gastroenteritis and pneumonia and nutritional problems.
Quality of Medical Care Accessibility to medical care was generally satisfactory with 58.5 of the children having
received outpatient andor preadmission treatment for the illness leading to the death, and for children who died in hospital, 62.2 had received care in intensive care units
and 79.9 had received care from specialist or consultant. However non availability of transport was thought to be responsible for 12.4 of all preventable deaths and 26.3
of preventable non hospital deaths and was the most important reason for preventability of non hospital deaths. For hospital deaths, non availability of ICU or ventilator bed was
thought to be responsible for 15 and no expertise for 6 of the preventable deaths. A number of findings in this study indicated delay in seeking or receiving appropriate
treatment. 71 children died while on the way to hospital or clinic, 17 died in the clinic and 85 in the AE Department and 220 16.9 deaths in hospitals occurred within 6 hours
and 437 33.6 deaths within 24 hours of admission. Although a large number of caregivers, 232 admitted to not being aware that the child was seriously ill, we also
wondered if our primary care providers were able to identify the seriously ill child as
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58.5 of the children had received treatment. We were also uncertain if the peripheral or referral centres were equipped and had trained personnel to manage and resuscitate
children. For preventable deaths due to peripheral or referral centres which included clinics and smaller hospitals, the most common reason given was delayed referral. Other
reasons given were poor stabilisation and one clinic did not have resuscitation facilities. Reasons given for preventable deaths due to treatment problems which included
underassessment, delayed or wrong diagnosis, inadequate resuscitation, inadequate or delayed treatment, poor antenatal or perinatal care and poor monitoring suggested there
was room for improvement in our medical services for these children.
Compared with other countries For the year 2006 the under 5 mortality rate for the world was 72 per thousand life births.
It ranged from a low of 6 for industrialized countries to a high of 186 in West and Central Africa. The rate for East Asia and Pacific was 29 and for South Asia 83.
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According to the report ‘The State of the World’s Children 2008 - Child Survival’, Malaysia ranked
number 138 out of 189 for under 5 survival, where the best ranking was 189 and included the countries Sweden, Singapore, San Marino, Iceland and Andorra. Sierra
Leone ranked number 1.
In our study, the 5 most common causes of death, excluding neonates were: 1. congenital malformations, deformations and chromosomal abnormalities
2. certain infectious and parasitic diseases 3. diseases of the respiratory system
4. diseases of the nervous system and 5. injuries, poisoning and external causes.
The World Health Organisation population bureau in 2006 listed the 10 leading causes of
death in children 0-14years in low and middle income countries and high income countries.
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For low and middle income countries they were 1. perinatal conditions
2. lower respiratory infections 3. diarrhoeal diseases
4. malaria 5. measles
6. HIV or AIDS 7. congenital anomalies
8. whooping cough 9. tetanus
10. road traffic accidents For high income countries, they were
1. perinatal conditions 2. congenital anomalies
3. road traffic accidents 4. lower respiratory infections
5. endocrine disorders 6. drowning
7. leukaemia
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8. violence 9. fires
10. meningitis
Conditions from the perinatal period was the most common cause of death regardless of income. In low and middle income countries 7 of the 10 leading causes of death were
infections whereas in high income countries congenital anomalies and injuries were more important causes of death. In Malaysia, congenital anomalies and injuries were
important causes of death but infections still remained as important causes as well.
Preventable factors Analysis of deaths of children 18 years old between 1995-1999 using the data collected
by the Arizona Child Fatality Review Program ACFRP determined that 29 of the deaths could have been prevented and preventability increased with the age of the child.
Only 5 of neonatal deaths were considered preventable, whereas the deaths of 38 of all children older than 28 days were considered preventable. After MVA deaths, medical
conditions were the second most common cause of preventable deaths and most of these occurred in the first year of life. Some of the reasons why the CFRTs believed a
medical death was preventable included inadequate emergency medical services, poor continuity of care, and delay in seeking care because of lack of health insurance. There
were 4 deaths resulting from infections that were vaccine-preventable. Strategies recommended to prevent these deaths include better access to medical care and better
training of emergency medical personnel in the diagnosis and management of paediatric patients.
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Many of the reasons for preventable deaths found in the ACFRP were also found in our study. Strategies recommended to prevent these deaths would also be applicable to us.
Accuracy in determination and documentation of cause of death Certification of deaths should be done by doctors or other trained medical personnel. For
hospital deaths, it was assumed all causes of death were appropriately determined and documented by medical personnel. But studies had shown that errors in death
certification were still very high even among doctors ranging from 25-78 in hospital based studies.
6,13
In a study done in Kuala Lumpur Hospital in 1999, a high percentage 75 of cause of death was not appropriately documented by medical officers.
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For non-hospital deaths in our study, 60 of the cause of death were certified by non- medical personnel and a large proportion were grouped under signs and symptoms. This
manner of reporting cause of death was not systematic and lacked accuracy. Verbal autopsy algorithm had been shown to be accurate with a sensitivity and specificity for a
fairly common cause of death of about 70.
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Verbal autopsy had been used as a tool in some under 5 years old mortality studies.
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